Patient counseling: Walking a tightrope

It was a busy day in the pharmacy. You know the drill. Prescriptions coming in every way imaginable: in person, by phone, by fax, and electronically. I almost expected a Western Union man to arrive with a stack of prescription telegrams. No matter how they come in, though, they all have to funnel out through the cash register. I was multitasking, trying to explain to someone in front of me the difference between Norco and Vicodin while keeping an ear on the cash-register conversation.

“Your insurance company wants some more information from your doctor before they’ll cover this prescription. It’s called a Prior Authorization.”

“But my doctor wrote the prescription. Isn’t that the authorization?”

You know how these conversations go. That’s when the customer did it. As the next sentence came out of my technician’s mouth, the customer closed his ears and started to stare straight at me. As if I were some sort of court of appeal.

He stood there for a good 5 minutes, until I had the time to come over and re-explain everything the technician had just told him, using almost exactly the same words. The customer wasn’t going to believe that his insurance had rejected his claim until he heard it from the mouth of the pharmacist.

That’s not the type of patient counseling they prepare you for in pharmacy school, but at my current job, repeating what a cashier is perfectly capable of communicating is a good part of my patient interaction. And it’s frustrating to no end.

When I worked on the less affluent side of town, I often had the opposite problem. It felt as if the shirt and tie and lab coat were at times a barrier to effective patient communication.

“Why did the pharmacist ask me if I smoked?” a patient once asked my technician. “Is it dangerous with this medicine?” She went on to say that she didn’t want to confess her tobacco use to me, but she smoked half a pack of cigarettes a day.

“Don’t tell him,” she said. “But will that make this medicine dangerous?”

In college I remember excruciatingly long debates at student APhA meetings over whether a technician should even be allowed to ask whether a patient wanted counseling or whether the offer had to come from an actual pharmacist. In the real world, I’ve learned that sometimes the only way to get a message to a patient is to send it through someone they’re willing to listen to.

Someone could probably write a book about the class, racial, economic, cultural, gender, and other factors that lead to my being expected to do too much communicating in the rich neighborhoods and too little in the poor ones. I wish someone would. Getting the balance right is the key to success in our profession. Every minute I spend re-explaining the concept of a prior authorization is one I can’t spend explaining the effects of tobacco use on oral contraceptives.

I’m not sure how we get to that balance, but I suspect a one-size-fits-all corporate approach works against what is needed. While I understand that the days of an independent drugstore in every neighborhood are long gone, I can’t help but wonder whether some flexibility in the chain-store model isn’t the wave of the future. Losing the lab coat where it serves to intimidate, putting the pharmacy glass back up where people demand our attention to deal with the irrelevant.

I think I might have just committed heresy against the overlords of our profession with that last sentence. The return of the glass! Sometimes though, I feel as if pharmacy could use its own Martin Luther. I can almost see someone tacking a list of grievances to the door at APhA headquarters.

Until that happens, I’ll be doing the best I can to find that communication balance, cursing the Prior Auth while trying to let others know I am nothing to be afraid of. Someday I may find it, but most likely I’ll still be looking for it on the day I retire.

Which is why they call it practicing pharmacy.